Severe Lactic Acidosis Due to Inappropriate Use of Biktarvy in a Patient With AIDS

Bictegravir-emtricitabine-tenofovir alafenamide is an approved medication for the treatment of acquired immunodeficiency syndrome (AIDS). This medication, also called Biktarvy, includes an integrase strand inhibitor combined with nucleoside reverse transcriptase inhibitors (NRTIs) to prevent viral DNA synthesis and lead to improvements in disease progression and mortality in patients with AIDS. A rare but previously documented adverse effect of NRTIs present in Biktarvy is lactic acidosis. NRTIs can cause lactic acidosis through mitochondrial impairment, as mitochondria depend on DNA polymerase gamma for replication. This enzyme is very similar to HIV's reverse transcriptase. Inhibition of mitochondrial production results in increased anaerobic metabolism and lactic acid production. We present a case where an inappropriately high dosage of Biktarvy in a patient with septic shock led to persistent lactic acidosis despite clinical improvement. After a thorough medication review, Biktarvy was temporarily held, and the lactic acidosis resolved. This clinical presentation stresses the importance of maintaining wide differentials for lactic acidosis and thorough medication reconciliation.